4.0 RECOMMENDATIONS 4.1 Hand-over Briefings The 273 occurrences examined at the outset of this study frequently involved lack of communications among the bridge team. TSB investigations of subsequent occurrences continue to show inadequate interpersonal communications among the bridge team. The results of the questionnaire demonstrate that, with respect to the need for communication, there are differences in perceptions and expectations between pilots and masters/OOWs. It appears that, in the absence of effective communication and exchange of information, both groups are making assumptions about each other's plans and actions, or lack thereof. In response to a general question about the effectiveness of communication, over 80% of each group agreed that communications are effective. However, when asked about specific information issues, respondents were less positive. Helm orders and other information, when communicated, are communicated well. What is important, however, is the information which is not passed on routinely. The responses to the questionnaire as well as the accident record demonstrate that, in many instances, passage plans, vessel characteristics, and local conditions are not communicated effectively. Even when watchkeeping officers are unsure of a pilot's intentions, it appears that many are reluctant to ask. There are many reasons offered for the information not being communicated. Many believe that the handling characteristics of Canadian-registered ships are well known to the pilots. Pilots may believe that Canadian officers are familiar with the routes and standard passage plans, so it is not necessary to discuss them. Another probable factor is habit, or normal procedures. If pilots were regularly asked to brief on their passage plan, they would probably come to expect it and prepare a briefing routinely. Similarly, if pilots asked routinely for information about the ship and her characteristics, bridge teams would be prepared to provide it. Normally, however, there is little information provided routinely and little apparent demand for it. Only when prompted on specific communication issues did either group comment unfavourably. In operational settings, people try to live up to expectations. It is obvious that neither pilots nor ship officers are expected to provide each other with much information, so they do not. If procedures which would encourage the exchange of information were implemented and enforced, it would become the norm over time. Given the chronic absence of effective communications among bridge officers and pilots resulting in a taciturn operating culture, the fundamental differences in expectations of the two groups frequently contributing to a lack of mutual understanding, and the demonstrated consequences of such misunderstanding, strong measures are required to enhance bridge team effectiveness through enhanced information exchange. Clearly, the current provisions in the CCG Recommended Code of Nautical Procedures and Practices regarding the exchange of information on navigation procedures, local conditions and the ship's characteristics are not being effectively applied. Therefore the Board recommends that: The Department of Transport require that, when a pilot commences duty in compulsory pilotage waters, there be a formal exchange of information between the master and the pilot with mandatory briefing elements for planned navigational procedures, local conditions and ship's characteristics. The Department of Transport ensure that training for Canadian ship officers and pilots include practice on the use of hand-over procedures to assist in the safe navigation of vessels in pilotage waters. 4.2 Language Language barriers on foreign ships continue to be a serious obstacle to the safe navigation of these vessels in pilotage waters. Since effective information exchange is vital to safe navigation, safety is compromised on those vessels where the pilots are unable to communicate with the crew. Not only do such language barriers lead to misunderstanding among the bridge team, but the bridge officers' situational awareness is compromised when they do not comprehend VTS or other radio communications and the pilot's workload is increased by the extra vigilance required in ensuring complete and timely compliance with directions. The Board notes the agreement of the Department of Transport with the intent of recommendation M95-01, made in the report of the collision on 22 July 1991 between the TUO HAI and the TENYO MARU. The recommendation stated that: The Department of Transport, working through the International Maritime Organization, seek stronger international measures to ensure that Member States, when issuing certificates of competency, adhere to the standard of language knowledge prescribed by the STCW. Accordingly, the Board is not recommending further safety action at this time. However, in view of the significance of this issue, as evidenced by the accident record and the comments received from parties in the industry, the Board continues to be concerned about the lack of adherence to the standard of language knowledge by Member States and will continue to monitor progress in this area. 4.3 Monitoring of Vessel Movements Several recent occurrences might have been prevented had there been an effective regime in place to monitor the progress of the vessel. All too often, a pilot's decision making can become the weak link in a system prone to single-point failure; i.e., in the absence of effective monitoring, there is little safety backup for the pilot in the navigation of the vessel. There is a significant difference in the stated experiences of masters/OOWs and pilots when it comes to the monitoring of the vessel movements under the conduct of a pilot. Almost all the masters and OOWs who responded stated that they always or often monitored the vessel movements and plotted her position. Only about half the pilots agreed that this was their experience. This difference in experiences might be due to a lack of communication. The masters and OOWs might indeed be regularly plotting and monitoring the vessel movements, but if this information is not being communicated to the pilot, he will indeed experience a feeling of being alone and solely responsible for the navigation of the vessel. Monitoring vessel movements and plotting her position are essential tasks in maintaining situational awareness while navigating a vessel. Situational awareness is impaired by inadequate feedback or information. The occurrences involving the CANADIAN EXPLORER, the HALIFAX and the IRVING NORDIC are examples of the vessel movements not being monitored and situational awareness being lost. Monitoring vessel movements is critical to safe navigation in compulsory pilotage waters. It depends on effective communication among the bridge team. In order for the OOW to effectively monitor the vessel movements, he should know the pilot's passage plan. For the pilot to maintain his situational awareness, he must be provided with feedback from the OOW on the vessel's position relative to the plan. The Board has previously recommended that: The Department of Transport require that the pilotage authorities publish official passage plans for compulsory pilotage waters and make them available to masters to facilitate monitoring of the pilot's actions by the vessel's bridge team. (TSB Recommendation M94-34, December 1994) Although the Department has rejected this recommendation, the Board notes that inadequate monitoring of a vessel's position is frequently associated with groundings and strikings. The Board considers that close and continuous monitoring of a vessel's progress following an agreed passage plan is essential for the safe conduct of the vessel. Accordingly, the Board further recommends that: The Department of Transport require that pilots, as part of their initial hand-over briefing: obtain the master's agreement to the intended passage plan; and invite the bridge team's support by having the officer of the watch plot and monitor the vessel's position at regular intervals and report the position to the pilot with respect to the agreed passage plan. 4.4 Teamwork Misunderstanding among the bridge team, lack of adequate information exchange, incomplete understanding of the intended manoeuvres, loss of situational awareness, absence of monitoring of the ship's progress, etc., as evidenced by the Canadian marine occurrence experience, are symptomatic of more fundamental problems in bridge practices. Such factors suggest deficiencies in the effectiveness of current bridge team management practices in compulsory pilotage areas. A lack of teamwork on the bridge of vessels in Canadian pilotage waters is continuing to compromise safe navigation. The recent occurrences involving the CONCERT EXPRESS, the LAKE ANINA, the MALINSKA, the HALIFAX and the IRVING NORDIC all point to a lack of communication and cooperation as contributing factors in the occurrences. As it has stated in the past, the Board continues to believe that increased emphasis on information exchange and coordination could improve bridge team management and therefore advance safe navigation. Systematic instruction of ship officers and marine pilots in operating practices and procedures designed to facilitate information exchange and coordination among all members of the bridge team is required. The overwhelming majority of pilots, masters and bridge officers who responded to the Board's questionnaire rated teamwork as important as technical proficiency for safe navigation. However, less than half of those who responded stated that they always worked as a team. The accident record confirms that current bridge procedures and practices frequently reflect an absence of teamwork. In rejecting the Board's Recommendation M94-34 regarding passage planning, the Department of Transport stated (22 March 1995): However, it is believed that a more effective bridge resource management regime (including enhanced communication between the pilot and the officer of the watch), rather than a voyage plan, may potentially have contributed to the incident being avoided. The Board notes the intention of the Department of Transport to develop optional training courses in Bridge Resource Management. However, the Board is concerned that optional training might not have the desired effect within the industry. Not all the major constituents of the marine industry have indicated strong support for such training. Bridge Resource Management, the managing of human and technical resources in an operational marine environment, is a function comprising several elements. These include the application of effective communication, the use of briefings and debriefings, and the creation of an environment where all members of the bridge team feel free to question assumptions and actions. As a result of the problems identified in this study relating to the absence of hand-over briefings, the ineffective monitoring of the vessel's position and in view of the frequency of occurrences involving demonstrated breaches of sound teamwork principles, the Board recommends that: The Department of Transport require that the initial training syllabus for all ship officers be modified to include demonstration of skills in Bridge Resource Management. The Department of Transport require that all ship officers demonstrate skills in Bridge Resource Management before being issued Continued Proficiency Certificates. The Department of Transport require that all pilots demonstrate skills in Bridge Resource Management before the issuance and/or renewal of a pilotage licence. The Board recognizes that unilateral action by one nation will not satisfactorily address the global issue of ineffectual teamwork with multinational crews on foreign vessels. Concerted action by leading maritime nations will be required to effect the cultural changes necessary to make BRM an accepted part of day-to-day bridge practices. Increased awareness of the benefits of formal BRM training to ensure safe and therefore profitable shipping operations will be required throughout the industry. Therefore, the Board recommends that: The Department of Transport, through the International Maritime Organization, actively promote the provision of formal training in Bridge Resource Management to all ship officers and marine pilots and the benefits of such training. 5.0 APPENDICES APPENDIX A TABULATION OF MASTER/PILOT EXPERIENCES The responses to the first 20 questions of the questionnaire are tabulated below. 1. In my experience, communication, teamwork and cooperation among all personnel on the bridge are as important as technical proficiency for safe navigation and ship handling. APPENDIX B TABULATION OF DEMOGRAPHIC INFORMATION Bridge Officers 52 responses 8 3 IMO International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, 1978 (STCW), Regulation II/1, paragraph 10.